Occasional Discomfort Research Articles

PWE-137 The role of 99mtechnetium-labelled hepato imino diacetic acid (HIDA) in the management of biliary pain

IntroductionBiliary pain is a common presentation in the acute surgical take and the surgical clinic. In patients with normal ultrasound findings, symptoms can sometimes be disregarded as being non-specific. We...

Thumb metacarpophalangeal joint ligament reconstruction with a triangular tendon graft in posttraumatic chronic instability

The purpose of this study was to report the results of static triangular ligament reconstruction, in thumb metacarpophalangeal (MCP) joint chronic posttraumatic laxity using a tendon graft with a proximal apex in ten patients. The mean postoperative follow-up was 40.2 months. The mean postoperative thumb MCP joint stress testing was 43° less than before surgery, and 6.5° less than in the non-injured hand. The mean range of flexion was 10.5° lower in the operated thumb than in the contralateral one, and the mean range of extension was 8° lower. Minimal differences in the values of the Kapandji score, grip and key-pinch strength were found. The preoperative pain became an occasional discomfort after surgery. All patients had a subjective sense of stability until final follow-up. All patients returned to their work or daily activities. Level of evidence IVFor therapeutic studies investigating the results of treatment.

Eosinophilic Esophagitis Presenting as Hiccups

Purpose: A 24 year old woman was referred to our care in March 2011 with a 3 year history of persistent hiccups and mild, intermittent dyspepsia. Her symptoms began with occasional mild chest discomfort lasting one minute followed by bouts of hiccups but progressed to up to ten episodes per day. She had no prior medical history other than one admission for renal calculi and her only prescription was birth control pills. She had no history of allergy and no known family history of illness as she was adopted. Six months before our evaluation she was treated empirically with ranitidine with no relief in her symptoms. She underwent esophagogastroduodenoscopy (EGD), which demonstrated trachealization of the esophagus and biopsies from the distal esophagus showed significant eosinophilic infiltration. She was subsequently placed on a 6 week course of high-dose omeprazole (40 mg twice daily), with minimal relief of her symptoms. A follow-up EGD showed persistent esophageal eosinophilia (peak eosinophils count of 23 per high power field) consistent with a diagnosis of eosinophilic esophagitis (EoE) (Figure 1). The patient was started on topical fluticasone (440 mcg twice daily). Within 1 week of treatment her symptoms improved substantially, with hiccups occurring fewer than 2 times per week. After 6 weeks her chest discomfort and hiccups resolved entirely. A post-treatment EGD demonstrated resolution of trachealization and histological remission of EoE. In conclusion, hiccups may be associated with eosinophilic esophagitis. Thus, EoE should be considered in the differential diagnosis of patients with refractory hiccups.Figure: Hematoxylin and eosin from esophageal biopsy shows large numbers of intraepithelial eosinophils as well as multiple degranulated eosinophils.

Adult Opisthorchis viverrini Flukes in Humans, Takeo, Cambodia

To the Editor: Opisthorchis viverrini and Clonorchis sinensis, the 2 major species of small liver flukes (family Opisthorchiidae), cause chronic inflammation in the bile duct, which leads to cholangitis and cirrhosis of the liver, and are a predisposing factor for cholangiocarcinoma (1). Human infections with O. viverrini flukes are found along riverside areas of Indochina (Thailand, Lao People’s Democratic Republic [PDR], and Vietnam) (2). Small trematode eggs (length 20–32 μm) have been found in human fecal samples in Cambodia (1,3,4). During 1981–1982, two of 102 Cambodian refugees in the United States were found to be positive for C. sinensis (likely O. viverrini) eggs (3). Egg-positive cases were later detected in several provinces of Cambodia (4,5). Presence of O. viverrini flukes in Cambodia was verified by detection of metacercariae in freshwater fish in a lake on the border between Takeo and Kandal Provinces and by isolation of adult flukes in experimentally infected hamsters (6). In May 2010, we analyzed fecal samples from 1,993 persons in 3 villages (Ang Svay Chek, Kaw Poang, and Trartang Ang) in the Prey Kabas District, Takeo Province, Cambodia, ≈45 km south of Phnom Penh, to confirm the presence of O. viverrini flukes among humans. We found an egg-positive rate of 32.4% for small trematode eggs. Because these eggs may be those of Haplorchis spp. flukes (H. taichui, H. pumilio, and H. yokogawai) and lecithodendriid flukes (Prosthodendrium molenkampi and Phaneropsolus bonnei) (1), we attempted to detect adult flukes that are responsible for these eggs. Six of the small trematode egg–positive villagers, 1 man and 5 women (age range 16–72 years), who had occasional epigastric discomfort were selected for anthelmintic treatment, purgation, and recovery of adult worms. Fecal examination and anthelmintic treatment of villagers were approved by the Ministry of Health, Cambodia, under the agreement with the Korea–Cambodia International Collaboration on Intestinal Parasite Control in Cambodia (2006–2011). After obtaining informed consent, the villagers were treated with a single oral dose of praziquantel, 40 mg/kg (Shinpoong Pharmaceutical Co., Seoul, South Korea), and given a purgament (solution containing 30–40 g MgSO4). Feces was obtained 3 or 4 times in a 2–3-hour period after purgation, pooled individually, and processed as described (7). Worms obtained were fixed with 10% formalin, stained with acetocarmine, and identified by morphologic features. A total of 34 O. viverrini adult worms were obtained from the 6 villagers (14, 9, 5, 3, 2, and 1 from each villager, respectively). No other species of trematodes were obtained. Five worms were lanceolate and had a mean length of 9.5 mm (range 6.5–12.0 mm), a mean width of 1.5 mm (range 1.2–1.7 mm), and 2 characteristic 4–5-lobulated testes (Figure, panel A). Ten eggs in uteri were 27 μm long (range 25–29 μm) and 15 μm wide (range 13–16 μm). Figure A) Adult Opisthorchis viverrini liver fluke (length 12.0 mm) isolated from a human after chemotherapy and purgation in Takeo Province, Cambodia, showing the characteristic morphology of the two 4–5-lobulated testes. B) Metacercaria of O. viverrini ... To detect the source of infection, 2 freshwater fish species, Puntioplites proctozysron (n = 5) and Cyclocheilichthys apagon (n = 10), were caught in nearby Ang Svay Chek village and examined for O. viverrini metacercariae by using a digestion technique (8). A total of 50 metacercariae (Figure, panel B) were obtained from 5 P. proctozysron fish and fed to a hamster. Six weeks later, 42 young O. viverrini flukes (Figure, panel C) were isolated from the biliary tract of the hamster. Our study identified only O. viverrini infections in humans in Cambodia. However, eggs of other hepatic and intestinal flukes also can be found in humans (1). In Thailand, Vietnam, and Lao PDR, opisthorchiids (O. viverrini and C. sinensis), heterophyids (Haplorchis spp., Centrocestus formosanus, and Stellantchasmus falcatus), and lecithodendriids have been found in humans (1,7,9). In several provinces in Lao PDR, mixed infections with O. viverrini and heterophyids or lecithodendriids were common (7,9), and the relative prevalence of each fluke species varied by locality. In Vientiane, Lao PDR, O. viverrini was the predominant species, whereas in Saravane Province, H. taichui predominated (7). In a mountainous area of Phongsaly Province, H. taichui and H. yokogawai worms were obtained from 10 villagers; however, no O. viverrini worms were detected (10). Thus, in Cambodia, the presence of human infections with intestinal flukes, including Haplorchis spp. and lecithodendriids, cannot be ruled out.

Sternal Plate Closure: Indications, Surgical Procedure and Follow-up

Titanium plate osteosynthesis (Synthes) is an alternative option for sternal closure. The indications and time point of application are still debated. This study investigated the application and feasibility of this technique after median sternotomy. Forty-one patients (29 M/12F, mean age 63 ± 17 years) received the plate system for complicated sternal conditions. Indications, intraoperative course and postoperative follow-up were assessed. Sternal deformity was present in 5 % (2/41), sternal fractures in 17 % (7/41), bone defect in 12 % (5/41), wire loosening in 39 % (16/41) and pseudoarthrosis in 27 % (11/41). 54 % (22/41) of patients showed concomitant sternal infection. Two intraoperative complications were noted: mammary artery injury (1 patient), pleural injury (1 patient). At discharge the patients reported no pain (90 %, 37/41) or only occasional discomfort (10 %, 4/41). Postoperative complications were subcutaneous hematoma in 12 % (5/41), seroma in 12 % (5/41) and sternal reinfection in 7 % (3/41). 12 % (5/41) showed occasional discomfort and 7 % (3/41) had persistent pain leading to plate removal. The Titanium Sternal Fixation System is comfortable and easy to use. It can be used to treat a wide spectrum of indications, especially for pseudoarthrosis, an entity which has not yet received sufficient attention.

Killing two birds with one stone

In September, 2008, a 56-year-old man presented to our department with fever, myalgia, pharyngitis, and a maculopapular skin eruption. He reported having unprotected sex with a man 2 months prior to the onset of his symptoms. He was diagnosed with HIV seroconversion illness in view of a high HIV viral load (>14 280 000 copies per ml) and a third generation HIV antibody test that was weakly positive. During routine HIV follow-up in March 2009, his previously normal alkaline phosphatase had risen to 486 IU/L and his alanine aminotransferase was 185 IU/L. His total bilirubin was 15 μmol/L. He had no symptoms except for mild occasional right upper quadrant abdominal discomfort. An abdominal ultrasound scan showed multiple large stones in the gallbladder but was otherwise normal. His antimitochondrial antibody was strongly positive (1:4000 IgG, M2 and M4 positive), consistent with a diagnosis of primary biliary cirrhosis. A liver biopsy showed damaged interlobular bile ducts, with granulomas, and increased amounts of eosinophilic cytoplasm and intraepithelial infl ammatory cells, also typical of primary biliary cirrhosis. In April, 2009, his CD4 count was 360 cells per μL, and he was started on tenofovir 245 mg, emtricitabine 200 mg, and efavirenz 600 mg once daily. In June, 2009, owing to central nervous system side-eff ects, efavirenz was changed to lopinavir 400 mg and ritonavir 100 mg tablets twice daily. Ursodeoxycholic acid was introduced at a dose of 15 mg/kg per day in November, 2009. His liver function tests improved considerably once antiretroviral therapy was introduced (fi gure). In May, 2010, after 13 months of treatment with anti-retroviral therapy, and 6 months of ursodeoxycholic acid, his liver function tests were normal. His antimitochondrial antibodies decreased to 1:250. Using a branched chain hybridisation assay (Quanti-Gene Aff ymetrix, California, USA) we found that serum from our patient was strongly positive for human betaretrovirus RNA. He was last seen in June, 2010, and was asymptomatic, with no clinical or biochemical evidence of cirrhosis. His HIV virus was completely suppressed and his CD4 count increased to 580 cells per μL. In 2003, a human betaretrovirus closely related to mouse mammary tumour virus was cloned from the biliary epithelium from patients with primary biliary cirrhosis. Viral infection of cholangiocytes with human betaretrovirus results in the aberrant expression of the mitochondrial E2 component of the pyruvate dehydrogenase complex. This protein, normally located on the inner mitochondrial membrane, appears on the cell surface in patients with primary biliary cirrhosis, and is thought to trigger the appearance of antimitochondrial antibodies. The relation between betaretrovirus infection and primary biliary cirrhosis is controversial. It has been suggested that randomised controlled trials with antiviral therapy may provide supportive evidence for a causal role of viral infection. Randomised controlled trials using combination lamivudine 150 mg and zidovudine 300 mg twice a day, have shown biochemical improvements in patients with primary biliary cirrhosis, but failed to achieve signifi cant endpoints, possibly because of the development of viral resistance to therapy. Other antiretrovirals that have proven eff ective against betaretrovirus in vitro, include: adefovir, tenofovir, and lopinavir. Here, we report that the combination of tenofovir, emtricitabine, lopinavir, and ritonavir used to manage HIV infection, coincided with marked reduction of cholestatic liver function tests, before the institution of ursodeoxycholic acid. If an association between primary biliary cirrhosis and human betaretrovirus infection can be established, the effi cacy of this highly active antiviral regimen can be tested in future controlled trials in patients with primary biliary cirrhosis unresponsive to ursodeoxycholic acid.

Cystic peritoneal mesothelioma: Report of a case

Benign multicystic peritoneal mesothelioma (BMPM) is a rare disease with good short-term prognosis and rare malignant transformation. However, its biological significance remains unexplained. A neoplastic origin is considered by many authors to require a surgical excision, based on the high recurrence and progressive growth rate of the tumors. However, alternative or integrative treatment options have also been proposed. A 45-year-old woman presented to our unit with a history of occasional discomfort and pain in the left hip. On physical examination, we noticed a tough-elastic, fixed mass located in the iliac fossa. Computed tomography scan detected a mass with multiseptated cystic-like areas. Due to the similarity of these findings to a primitive sarcomatous tumor of the retroperitoneum, an arteriographic study was also performed. The patient underwent en bloc resection of the mass, including a segment of the sigmoid colon. The final pathologic diagnosis was cystic mesothelioma. Further studies are needed to better understand the etiology and pathogenesis of this rare disease, and to define a more tailored treatment plan.

Single Incision Mid-urethral Sling for Treatment of Female Stress Urinary Incontinence

To present the longitudinal outcomes in an observational cohort of patients who had undergone treatment of stress urinary incontinence with a single incision mid-urethral sling (MUS). A prospective, observational study of all female patients who had undergone surgical intervention with the MiniArc MUS was performed. The surgical candidates underwent history and physical examination and urodynamic testing, as indicated. Quality of life questionnaires (Urogenital Distress Inventory [UDI-6] and Incontinence Impact Questionnaire [IIQ-7]) were administered preoperatively. The salient operative data were recorded. The patients were followed up postoperatively for evidence of treatment success and adverse events. The patients completed the UDI-6, IIQ-7, and Female Sexual Function Index questionnaires at 1 and 12 months after treatment. From September 2007 to October 2008, 120 patients underwent placement of the MiniArc MUS for the treatment of stress urinary incontinence. The mean patient age was 58.4 years. The mean body mass index was 27.2 kg/m(2). The mean preoperative daily pad use was 2.4. The mean preoperative IIQ-7 and UDI-6 score was 86.58 and 62.5, respectively. Of the 120 patients, 108 (90%) completed a minimum follow-up period of 12 months. Of these 108 patients, 101 (94%) were cured/dry. The mean postoperative pad use was 0.2 (P < .001). The mean IIQ-7 and UDI-6 score was 13.32 (P < .001) and 12.5 (P < .001), respectively. The Female Sexual Function Index results demonstrated no discomfort with intercourse in 49%, occasional discomfort in 9%, and frequent discomfort in 2%. The remaining 40% of our patients were not sexually active. Our results have shown that the MiniArc MUS offers excellent outcomes that are durable at 1 year after treatment.

Modified Chrisman–Snook repair for the treatment of chronic ankle ligamentous instability in children and adolescents

Chronic ankle ligamentous instability is not uncommonly encountered in children and adolescents. A number of operative procedures have been developed and described in the literature, including variations on the original Chrisman-Snook (CS) repair. The purpose of this study is to describe a modification of the CS repair and report the outcomes of this surgery for the treatment of chronic ankle ligamentous instability in children and adolescents. A retrospective review was conducted of 100 consecutive surgeries in 66 children performed by a single surgeon who modified the CS repair using a split peroneus brevis tendon to reinforce the anterior talofibular and calcaneofibular ligaments in chronic ligamentously lax patients. All charts were reviewed for complications. Fifty-three cases had at least a 2-year follow-up and were evaluated for the following outcomes: return to activity, ligamentous laxity, pain, and subsequent sprains. Of the 100 surgeries performed, no patient required repeat ligamentous repair. There were no deep wound infections. There were 10 cases of minor wound healing problems and two cases of temporary nerve dysfunction, one of which resolved without surgical intervention and the other is resolving with no plans for surgical intervention. There were two cases of sural nerve branch entrapment which required subsequent surgery due to neuroma formation. Of the 53 cases with at least a 2-year follow-up, the following outcomes were obtained: all patients returned to full activities of their choice; all but one case maintained ≤45° of ankle inversion postoperatively; all patients were pain free or had only occasional discomfort; and 23% of the ankles experienced subsequent minor sprains, but all were minor and resolved without consequence. A modification of the CS repair where the split peroneus brevis tendon is used to create ankle stability has been routinely successful in 100 consecutive cases of chronic ligamentous instability in children and adolescents with very few complications.

Neglected fracture of the medial humeral epicondyle that was entrapped into the elbow joint: a case report

The objective of this paper is to report clinical and radiographic long-term results of a neglected fracture of the medial humeral epicondyle, which was entrapped into the elbow joint. At follow-up, 48 years after the trauma, the patient complained of occasional discomfort around the elbow, but the joint had a normal range of motion and good stability. Radiographs showed that the epicondylar fragment was fused to the medial border of the olecranon. The authors conclude that an old fracture of the medial humeral epicondyle, presenting a fusion of the fragment to the olecranon with normal range of motion and without pain, may be managed expectantly.

Fracture Dislocation of the Glenoid Fossa With Open Physis: A Case Report

Scapular fractures are uncommon injuries that account for 1% of all fractures. Ten percent of these lesions involve the glenoid fossa and intraarticular displacement is rare, not exceeding 10% of the cases. The classification of intraarticular glenoid fractures was described by Ideberg on the basis of his findings in 100 patients with this type of injury. His classification, however, does not include a dislocation of the glenoid fossa without displacement of the humeral head. We report the case of a fracture dislocation of the glenoid fossa without displacement of the humeral head in a patient with open physis. Our surgical approach and results after 6 years of follow-up. Six years postoperatively the patient has minimal occasional discomfort and a full range of motion and strength, even in external rotation. Shoulder stability is also normal. Her Constant score is 97. The fracture is actually healed clinically and radiographically with no evidence of post traumatic articular degenerative disease or avascular changes. The fracture/dislocation of the glenoid fossa is an uncommon injury that can be effectively treated by open reduction and internal fixation. A posterior surgical approach was useful to achieve anatomic reduction and strong fixation in this case presentation.

Total Extraperitoneal Laparoscopic Inguinal Hernia Repair Without Mesh Fixation

To determine the outcomes of patients undergoing total extraperitoneal inguinal hernia repair without fixation of the mesh. Prospective cohort. Community teaching hospital. A total of 274 consecutive patients were included in the study group. All operations were performed by the same surgeon with the patients under general anesthesia in an outpatient setting. A preformed polyester mesh (Parietex; Covidien, Mansfield, Massachusetts) was used in all cases without any fixation. All patients were prospectively followed up at 2 weeks, 1 month, and 1 year after surgery. Operative morbidity, chronic pain, and hernia recurrence were recorded. Two hundred seventy-four consecutive patients underwent 311 total extraperitoneal inguinal hernia repairs. No conversions were made to open hernia repairs. No recurrences were found at the 12-month follow-up visit. There were 19 inguinal seromas (6.1%) identified at 2 weeks, but only 7 (1.9%) remained at 1 month, and none at 1 year. No wound infections, scrotal hematomas, or other perioperative complications were reported. Two hundred thirty-six patients used fewer than the 30 prescribed tablets for pain control, while 23 patients requested a refill, 12 of whom had seromas (P < .01). At 12 months, no patient was taking pain relief medication; however, 8 patients reported occasional discomfort in the groin, and 1 patient reported occasional umbilical discomfort. This single general surgeon experience supports total extraperitoneal inguinal hernia repair without mesh fixation as a safe, effective procedure with low morbidity and no evidence of recurrence at the 1-year follow-up visit.

Usefulness of 64-Slice Coronary Computed Tomographic Angiography in the Planning of Percutaneous Coronary Intervention

) with a 2-year history of adult-onset diabetes mellitus pre-sented with dyspnea on exertion and occasional chest discomfort. An electrocardiogram suggested previous inferior wall myocardial infarction of undetermined age. A myocardial perfusion stress test, performed at an outside institution, demonstrated inferior wall myocardial ischemia. The patient was initially unwill-ing to undergo invasive coronary angiography but was amenable to noninvasive, coronary computed tomo-graphic angiography (CCTA). A 64-slice gated CCTA demonstrated only mild narrowing of the left system

Endoscopic transpapillary gallbladder drainage for Mirizzi syndrome accompanied with obstructive suppurative cholecystitis

Objective To evaluate endoscopic transpapillary gallbladder drainage （ETGD） for Mirizzi syndrome accompanied with acute obstructive suppurative cholecystitis. Methods Data of 8 cases, who presented with acute right upper quadrant abdominal pain and positive Murphy sign and were diagnosed by imaging and endoscopic retrograde cholangiopancreatography （ERCP） as having Csendes type Ⅰ of Mirizzi syndrome, were retrospectively studied. The cholelithiasis with obstructive suppurative cholecystitis were treated with stone removal via ERCP and subsequent ETGD. Results ETGD was successfully performed in all patients, and no complications or death occurred. The symptoms relieved after the procedure, and body temperature and white blood cells gradually decreased to normal level. Imaging findings one week after ETGD showed subsidence of gallbladder inflammation. All patients remained symptom free at follow-up of 6 months, except occasional discomfort in gallbladder area in 2 patients. Conclusion Endoscopic treatment is safe and effective in patients with Mirizzi syndrome. ETGD is able to relieve infection and clinical symptoms in such patients accompanied with acute suppurative cholecystitis. Key words: Cholecystitis ; Cholangiopancreatography, endoscopic retrograde ; Mirizzi syndrome ; Endoscopic transpapillary gallbladder drainage

Arthroscopic repair of rotator cuff tear with anchor and transosseous suture

Objective To discuss the surgical methods and techniques of rotator cuff tear repair with anchor and transosseous suture and evaluate the clinical outcomes. Methods From February 2007 to February 2009, 32 cases of various types of rotator cuff tear were treated arthroscopically. The rotator cuff was repaired with suture anchor and transosseous suture. Twenty-five cases had full thickness tear, 5 had partial bursa-side tear,and 2 had partial articular-side tear. Sixteen lesions were on the dominant side. Preoperatively X-rays of the shoulder at the anteroposterior and supraspinatus outlet projection were obtained in all cases. Eleven patients had undergone MRI examinations and 21 cases had MRA. All the patients underwent acromioplasty. Eighteen cases were treated by single roll suture anchor and 1 or 2 transosseous tunnel suture, while 14 cases were treated by double roll suture anchor and 1 or 2 transosseous tunnel suture. UCLA scoring system was adopted to evaluate shoulder function before the operation and at the final postoperative follow up. Results All 32 cases were followed up for 3 to 23 months, with a mean interval of 13.4 months. The average UCLA score was 13.3 preoperatively and 33. 1 postoperatively. Twenty-three cases were rated as good and 9 cases as fair. Pain disappeared in 21 cases, while occasional and mild pain and discomfort still existed in 5 cases. In 6 cases pain was triggered by massive movement or special maneuvers. Normal shoulder movement was achieved in 24 cases. Active forward flexion and abduction reached > 150° in 26 cases and 90° to 120° in 6 cases. Muscle power of forward flexion and abduction was M5 in 25 cases and M4 in 7 cases. All the patients were satisfied with the surgical outcomes. Conclusion Arthroscopic repair using anchor and transosseous suture is a good method for repairing rotator cuff tear. This technique leads to secure fixation and hence ensures rotator cuff to bone healing. It is especially suitable for patients with osteoporosis or for revision cases. Key words: Shoulder joint; Reconstructive surgical procedures; Arthroscopes

Muscle Prolapse After Harvesting Autogenous Fascia Lata Used for Frontalis Suspension in Children

To evaluate the long-term results at the donor site in children who underwent harvesting of autogenous fascia lata for frontalis suspension in ptosis correction. The study design consists of a retrospective, nonrandomized case series. Medical records of 30 patients were reviewed. Each patient was reexamined, evaluating bulging at the donor site. Muscle prolapse was graded as not visible and not palpable, not visible but palpable, mildly visible, or obviously visible. Measurement of the width and length of the leg scar was recorded. Discomfort at the donor site was graded as no discomfort, occasional discomfort, or frequent discomfort. The mean age of the patients was 7 years (range, 1-15), with a mean follow-up period of 27 months (range, 3-63 months). Fifteen patients (50%) had invisible and impalpable bulging, 2 patients (6.7%) had invisible but palpable bulging, 5 patients (16.7%) had mildly visible bulging, and 8 patients (26.7%) had obviously visible bulging. The mean width of the scar was 7.5 mm, and the mean length was 3.6 cm. Twenty-seven patients (90%) had no functional discomfort of the leg, 2 patients (6.7%) had occasional discomfort, and 1 patient (3.3%) had frequent discomfort that occurred during exercise. After fascia lata harvesting, most patients had no cosmetic complaints or functional complications. The technique of harvesting fascia lata using a Crawford stripper seems to be safe and satisfactory.

Management strategies in isolated pancreatic trauma

In the absence of damage to other organs, pancreatic injury is rare. We have reviewed our experience with isolated pancreatic injury. Patients treated for isolated pancreatic trauma at our unit were identified prospectively and then retrospectively entered onto a database. The mode of presentation, mechanism of injury and management strategies were reviewed. Seven male and four female patients, median age 30 years (range 13-51 years) were treated. All suffered blunt abdominal trauma with different mechanisms of injury, each being characterised by a direct blow to the central abdomen. In two patients, somatostatin analogue treatment used as primary treatment resulted in early resolution of symptoms and signs. Six patients underwent surgery at various stages post-injury. At a median follow-up of 58 months (range 22-106 months), eight patients are asymptomatic, two patients have chronic pain following distal pancreatectomy and one patient has occasional discomfort. Confirmation of the mechanism of trauma and suspicion of pancreatic injury are essential for early diagnosis and appropriate management. Early contrast computed tomography examination is vital in the recognition of these injuries. Somatostatin analogue therapy may have an important role in the treatment regimen, especially when patients present early after sustaining a pancreatic injury. Only selected patients require open surgery.

Predictive Factors of Subtle Residual Shoulder Symptoms after Transtendinous Arthroscopic Cuff Repair

Background Transtendinous repair is a well-known technique for the arthroscopic management of partial rotator cuff tear. However, there are not a lot of clinical follow-up studies in the literature reporting data on this approach, and, moreover, potential factors responsible to influence the outcomes have not been investigated. Purpose To evaluate clinical outcomes after arthroscopic transtendinous repair and to identify predictive factors of residual shoulder symptoms. Study Design Case series; Level of evidence, 4. Methods Fifty-four patients with a mean age of 56.7 ± 8.8 years (range, 31-71 years) who had undergone an arthroscopic transtendon repair for a painful articular-sided rotator cuff tear with a minimum of 2 years of follow-up were contacted. Clinical outcomes using a patient-based questionnaire, the Constant score, University of California at Los Angeles score, Simple Shoulder Test, and visual analog scale were evaluated. The influence of patient age, presence or absence of a trauma responsible for the cuff tear, presence of associated shoulder lesions, millimeters of exposed footprint, and millimeters of torn tendon retraction on the outcomes were assessed. Results The mean cuff tear exposure footprint was 5.2 mm, and the mean retraction of the torn part of the tendon was 8 mm. Only one patient reported dissatisfaction with surgery because of persistence of pain during overhead activities. After arthroscopic repair, University of California at Los Angeles, Constant, and Simple Shoulder Test scores were significantly improved from 14.1, 45.3, and 9.8 to 32.9, 90.6, and 0.8, respectively (P < .001). Twenty-two patients (41%) reported occasional shoulder discomfort at the extremes of range of motion (particularly at extremes of abduction and internal rotation) occurring during some daily living and sports activities. The best multivariate model showed that residual shoulder discomfort is strongly linked with a partial thickness supraspinatus tendon avulsion-type articular-sided rotator cuff lesion consisting of a large tendon retraction and/or a relatively small exposure footprint area in an older patient in the absence of a specific trauma (P < .001). Conclusion Arthroscopic transtendon partial articular supraspinatus tendon avulsion-type rotator cuff repair was a reliable procedure that resulted in a good outcome in terms of pain relief and shoulder scores in 98% of the 54 patients. Better results could be expected in patients with less tendon retraction, a larger footprint exposure, of younger age, and with a clinical history of trauma.

No way in &amp; no way out: a case of renal failure due to both pre- and post-renal obstruction

A 46-year–old lady presented to the renal physicians in 2002 with a biopsy diagnosis of Langerhans cell histiocytosis (LCH). Initial presentation had been with maxillary and retro-orbital disease. A CT scan of the thorax/abdomen/pelvis in 2002 had shown extensive irregular soft tissue around and extending into the sinuses of both kidneys (Figure 1), with renal calyceal but not pelvic dilatation, as well as disseminated involvement including bone, mediastinum and lungs. Her serum creatinine was normal and a MAG3 renogram showed no evidence of functional obstruction. She had no symptoms other than occasional loin discomfort. Three years later she developed worsening hypertension, a rising serum creatinine and pulmonary oedema. MR angiography showed bilateral tight renal artery stenosis. It again showed the unusual pattern of strikingly dilated calyces but collapsed renal pelves. Dynamic renography and antegrade pyelography (Figure 2) indicated obstruction at the level of the renal pelvis bilaterally. Consequently, percutaneous nephrostomies were placed, but there was no improvement in renal function.

Long-term discomfort after plug and patch hernioplasty

collected 5 years after hernioplasty by an expert in locating people. Of 839 patients, 764 (91%) were contacted by a physician and answered a telephone questionnaire. Only 75 patients were lost at follow-up because of change of address. Among the more important questions were: Do you feel any painful sensation? Do you feel anything abnormal in the groin? Do you have any recurrence or any other symptom? All patients (119 of 764) complaining of any sign consistent with discomfort or painful sensation throughout the groin attended a physical examination by an independent surgeon, with experience in hernia surgery. As in the study of Berndsen, the importance of pain was graduated as mild (occasional discomfort or pain that does not interfere with daily activity), moderate (discomfort or pain that occasionally interferes with daily activity) and severe (discomfort or pain that interferes with daily activity). Results are shown in Table 1. At physical examination, 19 of 24 patients turned from moderate to mild. Overall discomfort after 5 years was 6.5%, with only 0.9% of patients complaining of moderate (0.6%) or severe (0.3%) pain. We found no relationship between late discomfort and early postoperative pain. On the contrary, a correlation with preoperative pain was evidenced, but it was not statistically signiWcant. Our results from this large series, with high follow-up percentage (91%) and supplemental physical examination after 5 years, have demonstrated that the incidence of late discomfort after plug and patch hernioplasty is as low as it is for the TAPP procedure in Berndsen’s study. Our present purpose is not to compare late results of plug and patch repair with that technique but to stress that the true incidence of long-term discomfort after prosthetic hernioplasty could not be as high for all well-standardised techniques as believed.